The Incidence of Abortion in Nigeria.pdf

International Perspectives on Sexual and Reproductive Health
170
Induced abortion is illegal in Nigeria except when per-
formed to save a woman’s life. Both the penal code, which
is generally applied in the country’s northern states, and
the criminal code, which generally applies in the south-
ern states, allow this exception, and both regions specify
similar criminal penalties for noncompliance.1
Yet preg-
nancy terminations are quite common, and because they
are often performed clandestinely or by unskilled provid-
ers, most are unsafe.2
The first national study to examine
the incidence of abortion estimated that in 1996, about
610,000 abortions, or 25 per 1,000 women aged 15–44,
occurred in Nigeria.3
A decade later, another study noted
that if the abortion rate had not changed since 1996, then
760,000 abortions would have occurred in 2006, given the
increase in Nigeria’s population during this period.4
Since the release of the 1996 estimates, the Nigerian
government and other stakeholders have initiated a num-
ber of policies and programs to improve the reproductive
health of women in the country. Notable among them are
the government’s efforts to achieve the United Nations Mil-
lennium Development Goals, including Goal 5, to improve
maternal health. This goal has two targets: to reduce the
maternal mortality ratio by 75% between 1990 and 2015,
and to provide universal access to reproductive health by
2015. A 2010 government report concluded that progress
toward achieving these targets has been slow, and that the
modest progress that has been made in reducing maternal
mortality has not been accompanied by improvements in
other indicators, such as family planning uptake and the
proportion of births attended by skilled health workers.5
In the hopes of better understanding the scale of clan-
destine abortion and related reproductive health issues
facing Nigerian women, we present new estimates of the
incidence of induced abortion in Nigeria, at the national
level and for each of the country’s six geopolitical zones.
METHODS
Data Sources
We produced our estimates using the Abortion Incidence
Complications Methodology (AICM), an indirect approach
that has been used to estimate the incidence of abortion
in more than 15 countries.6–9
The methodology relies on
data collected through two surveys: a Health Facilities
Survey, which gathers information from facilities that treat
postabortion patients (i.e., women with complications
from induced or spontaneous abortions), and a Health
Professionals Survey, which collects information about
abortion provision from knowledgeable key informants.
These surveys are described in detail below. In addition,
we used fertility and other data from the 2013 Nigeria De-
mographic and Health Survey (NDHS)10
and population
estimates from the United Nation’s 2012 revision of the
CONTEXT: Because of Nigeria’s low contraceptive prevalence,a substantial number of women have unintended
pregnancies,many of which are resolved through clandestine abortion,despite the country’s restrictive abortion
law.Up-to-date estimates of abortion incidence are needed.
METHODS: A widely used indirect methodology was used to estimate the incidence of abortion and unintended
pregnancy in Nigeria in 2012.Data on provision of abortion and postabortion care were collected from a nation-
ally representative sample of 772 health facilities,and estimates of the likelihood that women who have unsafe
abortions experience complications and obtain treatment were collected from 194 health care professionals with a
broad understanding of the abortion context in Nigeria.
RESULTS: An estimated 1.25 million induced abortions occurred in Nigeria in 2012,equivalent to a rate of 33
abortions per 1,000 women aged 15–49.The estimated unintended pregnancy rate was 59 per 1,000 women aged
15–49.Fifty-six percent of unintended pregnancies were resolved by abortion.About 212,000 women were treated
for complications of unsafe abortion,representing a treatment rate of 5.6 per 1,000 women of reproductive age,
and an additional 285,000 experienced serious health consequences but did not receive the treatment they needed.
CONCLUSION: Levels of unintended pregnancy and unsafe abortion continue to be high in Nigeria. Improvements
in access to contraceptive services and in the provision of safe abortion and postabortion care services (as permit-
ted by law) may help reduce maternal morbidity and mortality.
International Perspectives on Sexual and Reproductive Health,2015,41(4):170–181,doi:10.1363/4117015
Akinrinola Bankole is
director of inter-
national research,
Rubina Hussain is
research associate
and Susheela Singh
is vice president for
research—all at the
Guttmacher Institute,
New York. Isaac F.
Adewole is vice chan-
cellor and professor,
and Olutosin Awolude
is a consultant and
lecturer, Department
of Obstetrics and Gyn-
aecology; and Joshua
O. Akinyemi is a
lecturer, Department
of Epidemiology and
Medical Statistics—all
at the University of
Ibadan, Nigeria.
By Akinrinola
Bankole,Isaac F.
Adewole,Rubina
Hussain,Olutosin
Awolude,Susheela
Singh and Joshua
O.Akinyemi
The Incidence of Abortion in Nigeria

Volume 41,Number 4,December 2015 171
ters (mostly primary-level); and 17% of private maternity
centers (again, mostly primary-level). In addition, because
of their large postabortion care caseload, we included all
tertiary facilities (teaching hospitals and federal medical
centers) in the country, regardless of whether they were
located in sampled states. After exclusion of 45 facilities
that no longer existed or were not found, the final sample
consisted of 1,088 facilities.
Trained interviewers visited each sampled facility be-
tween July 2011 and March 2012, and used a standardized
questionnaire to conduct a face-to-face interview with a
senior staff member knowledgeable about the facility’s
provision of abortion services. Respondents were chosen
onthebasisoftheirseniorityaswellastheirfamiliaritywith
abortion-related services at their facility; they either over-
saw abortion or postabortion care at the facility, or were the
only provider or one of the few providers of such services.
Interviewers, with the support of their supervisors, were
responsible for using these criteria to locate appropriate
respondents. In some instances, the identified respondent
was unavailable or was unable to complete an interview.
In these cases, the interviewer made multiple attempts
to interview the respondent; if this was not possible,
the interviewer sought an interview with the next most
knowledgeable person, if there was more than one
provider.
The response rate for the survey was 98%. An initial
analysis found that 314 facilities in our sample did not offer
postabortion care, and two that did offer such services had
not responded to a number of key questions; these facili-
ties were removed from our analysis. Of the remaining 772
World Population Prospects in our calculations.11
The study
was approved by the Guttmacher Institute’s institutional
review board and by the University of Ibadan Ethical Re-
view Committee.
Health Facilities Survey
All public and private health facilities that had the capacity
to provide postabortion care services were included in the
sample frame for the survey. We compiled a list of poten-
tially eligible health facilities using the most recent (2007)
National Bureau of Statistics’ Directory of Health Establish-
ments in Nigeria, supplemented by information from the
2007 National Health Insurance Scheme and the Ministry
of Health’s Department of Hospital Services. Slightly more
than 5,000 facilities were deemed eligible.
It was important to represent all six of Nigeria’s geo-
political zones, because women’s social and demographic
characteristics vary greatly across the country, particularly
between the northern and southern zones.* Therefore, us-
ing information from the Nigerian census and the 2008
NDHS,†
we grouped the states in each zone into tertiles
according to the proportion of women who lived in urban
areas, and randomly selected one state per tertile (and
thus three states per zone). This yielded a total of 18 states
across the country: Kaduna, Kebbi and Jigawa in the North
West; Bauchi, Borno and Taraba in the North East; Kwara,
Nasarawa and Niger in the North Central; Abia, Anambra
and Imo in the South East; Cross River, Edo and Rivers
in the South South; and Lagos, Ogun and Ondo in the
South West.
A total of 3,125 facilities that potentially provided post-
abortion care were located in the 18 states. We randomly
selected 75% of public secondary hospitals (general, spe-
cialist and district-level), comprehensive health centers,
cottage hospitals and public clinics; 40% of private hospi-
tals, clinics and medical centers (a mixture of secondary-
and primary-level facilities); 40% of public maternity cen-
*Residents of the northern zones are largely Muslim,whereas the south-
ern zones’ population is primarily Christian. In addition, the proportions
of women who live in urban areas and levels of female education are
lower in northern zones than in southern ones.Compared with the other
zones, the North West and North East zones have lower contraceptive
prevalence and higher fertility.
†At the time of sampling,the 2013 NDHS was not available.
TABLE 1. Number of surveyed facilities that provided postabortion care,and estimated total number of facilities that provided such care,by facility
type,according to geopolitical zone,Health Facilities Survey,2012
Facilitytype Surveyed Estimatedtotals
Geopoliticalzone All %
distri-
bution
Geopoliticalzone All %
distri-
bution
North
West
North
East
North
Central
South
West
South
South
South
East
North
West
North
East
North
Central
South
West
South
South
South
East
Public/government 51 114 62 41 60 41 369 47.8 259 487 204 136 173 88 1,347 34.7
Teachinghospital/FMC 9 7 8 6 5 12 47 6.1 14 7 9 14 10 13 67 1.7
General/specialisthospital 31 44 31 24 26 15 171 22.2 115 81 101 68 78 44 487 12.6
Cottagehospital/CHC/clinic 4 9 17 8 29 11 78 10.1 23 14 68 33 85 23 246 6.3
Maternitycenter 7 54 6 3 0 3 73 9.5 107 385 26 21 0 8 547 14.1
Private* 68 42 76 92 59 66 403 52.2 402 190 619 426 441 454 2,532 65.3
Hospital 36 18 45 84 33 47 263 34.1 131 84 327 353 210 245 1,350 34.8
Clinic/medicalcenter 9 15 11 6 23 4 68 8.8 75 56 91 41 163 24 450 11.6
Maternitycenter 23 9 20 2 3 15 72 9.3 196 50 201 32 68 185 732 18.9
All 119 156 138 133 119 107 772 100.0 661 677 823 562 614 542 3,879 100.0
*Includes 31 facilities operated by nongovernmental organizations or missions.Notes: Percentages may not total 100.0 because of rounding.FMC=Federal medical center.
CHC=Comprehensive health center.

172
respondents were nurses, midwives, community health ex-
tension workers or community health officers (74–93%).
General and specialist hospitals and private maternity cen-
ters had a more balanced mix of respondents.
All respondents provided informed consent; they did
not receive remuneration for participating. Respondents
were asked to estimate the number of patients who re-
ceived postabortion care (for complications of either spon-
taneous or induced abortion) at their facility as outpatients
and inpatients. To accommodate the large variation in fa-
cility size and capacity, we offered respondents three time
periods (week, month and year) for which to make their
estimates, but asked them to answer for only one. They
provided estimates for both the average week, month or
year, and the past week, month or year. We asked for these
two types of estimates to increase the likelihood of accurate
recall and of capturing variation within the year. Respons-
es were converted to annual totals and averaged to provide
an estimate for the calendar year. Respondents were also
asked to estimate the number of induced abortions per-
formed at the facility during the same time periods.
In examining the data from the Health Facilities Survey,
we became concerned about the accuracy of some results,
because the proportion of facilities that reported providing
abortions was very small, regardless of facility type. In the
Health Facilities Survey conducted for the 1996 estimate
of abortions incidence in Nigeria, 33% of respondents in-
dicated that their facility provided induced abortion ser-
vices;3
in the current study, only 8% of respondents report-
ed that their facility performed abortions (Appendix Table
1). Private clinics and medical centers were the most likely
to report providing this service (21%), followed by teach-
ing hospitals and federal medical centers (14%).
We hypothesized that because of growing social conser-
vatism throughout Nigeria and the inhibiting effects of a
new antiabortion stance in the national (and a number of
state) legislative houses, some respondents were misclas-
sifying pregnancy terminations—probably intentionally—as
cases of postabortion care. The defeat of the 2006 repro-
ductive health bill in the Senate (largely because it was con-
sidered an abortion bill), and the 2013 repeal of a 2012
law that, among other things, had expanded the criteria for
legal abortion in Imo state, exemplify the increasing level of
social conservatism in Nigeria.14
Moreover, in a 2009 study,
nearly one-third of 49 Nigerian policymakers surveyed said
that abortion should not be allowed even to save a wom-
an’s life.15
Because our respondents’ apparent misreport-
ing of the number of abortions performed at their facility
would have resulted in our overestimating the number of
postabortion care patients treated in Nigeria, we adjusted
their estimates in accordance with our experience from a
similar study we had conducted (see Appendix, page 179).
Health Professionals Survey
The Health Professionals Survey was designed to elicit
respondents’ perceptions regarding various aspects of
abortion provision in Nigeria and the potential health con-
facilities, 48% were in the public sector, and 52% were pri-
vate or were operated by nongovernmental organizations
or missions (Table 1, page 171). For each geographic zone,
we assumed that the proportion of facilities in our sample
that did not provide postabortion care was representative
of the zone as a whole, and proportionally reduced the
universe of facilities that provide such services in the zone,
resulting in an estimate that 3,879 facilities provide post-
abortion care nationally.
Most of the facilities included in this study provided
both inpatient and outpatient services (Appendix Table 1,
page 177). The majority of high-level government facilities
(teaching hospitals, federal medical centers, and general
and specialist hospitals) and private facilities had func-
tional manual vacuum aspiration (MVA) equipment; the
proportion ranged from 62% for private maternity centers
to 98% for teaching hospitals and federal medical centers.
Fifty percent of cottage hospitals and other community
health centers had functioning MVA equipment, but only
10% of government maternity facilities did. With the ex-
ception of government maternity centers, the majority of
facilities in each category had staff trained in use of the
equipment. All teaching hospitals, federal medical centers,
and general and specialist hospitals had surgical wards, as
did more than 90% of private hospitals, clinics and medi-
cal centers. Most teaching hospitals and federal medical
centers (84%) also reported having a separate ward for
abortion-related services.
Because of staff shortages and inadequate resources,
record-keeping is inadequate at facilities in many develop-
ing countries. For example, a recent study found medical
record-keeping in six tertiary facilities in Nigeria to be poor
in both completeness and quality,12
and only 46% of sam-
pled facilities in a 2008 Colombian AICM study were able
to provide adequate information for the study year, lead-
ing the authors to argue that “data maintained by facili-
ties are currently too incomplete to be the basis of national
estimates of abortion incidence.”13(p.116)
Because we had
similar concerns, we did not rely on official facility records
to help us determine the number of postabortion care
cases or pregnancy terminations at the facility. Instead, we
obtained caseload estimates for each facility from the
knowledgeable senior staff member who was interviewed
for the survey.
Of the 772 surveyed respondents, 52% were obstetri-
cian/gynecologists, general practitioners, other physicians
or medical officers; 33% were nurses or midwives; 14%
were community health extension workers or community
health officers; and fewer than 1% were other staff (Appen-
dix Table 2, page 178). Fifty-seven percent of respondents
had at least 10 years of work experience, 41% were female
and 70% were aged 30–50 (not shown). In public teach-
ing hospitals and federal medical centers, and in private
hospitals, clinics and medical centers, a large majority of
respondents were physicians or medical officers (66–72%;
Appendix Table 3, page 178), while in public cottage hospi-
tals, comprehensive health centers and public clinics most

proxy proportions, we estimated that 142,430 women
received care for spontaneous abortion in 2012, and sub-
tracted this number from the total number of postabortion
care patients to obtain an estimate of the number treated
specifically for complications of induced abortion.
The next methodological step relied on responses of
the knowledgeable health professionals. One of three out-
comes is likely for women obtaining clandestine abortions:
They may experience no health complications, or none se-
rious enough to require care; they may experience compli-
cations, but not receive care; or they may have complica-
tions and obtain the care they need. Reasons for women’s
not receiving care include stigma, cost, distance to a health
facility and death before having a chance to receive care. Ap-
plying a number called a multiplier to the number of wom-
en treated for complications of induced abortion accounts
for the women who do not need or receive treatment, and
produces an estimate of the total number of abortions.
For example, a multiplier of 4.0 means that one in four
women who had an induced abortion received treatment
for complications in a health facility. A small multiplier re-
flects either that abortion is generally unsafe or that access
to medical care is high, whereas a large multiplier indicates
that abortion is very safe or that many women do not have
access to medical care. We calculated separate multipliers
for each region (see Appendix for further details).
Because of the uncertainty inherent in our estimates, we
calculated 95% confidence intervals around the total num-
ber of abortion complications (induced and spontaneous)
treated in health facilities. We then applied the methodol-
ogy described above to the low and high estimates of the
number of treated complications to produce upper and
lower estimates of abortion incidence (number and rate).
RESULTS
Treatment for Abortion-Related Complications
After adjustment of the original Health Facilities Survey
data (see Appendix), we estimate that 354,400 women
were treated for complications of spontaneous or induced
abortion in Nigeria in 2012 (Table 2, page 174). Slightly
more than half of these women (54%) were treated in pub-
lic facilities (not shown); the proportion varied by region,
ranging from 34% in the South South to 78% in the North
East, likely reflecting differences in the availability and
accessibility of private-sector facilities. Only in the South
South and South East zones did public facilities treat fewer
than half of patients who received postabortion care. Na-
tionally, the majority of patients were treated at large hos-
pitals, both in the public sector (59%) and private sector
(56%). However, the situation varied among regions; for
example, in the public sector, the proportion of women
treated at hospitals ranged from 35% in the North Central
region to 82% in the North West region.
After subtracting the number of women who had been
treated for complications of late spontaneous abortions,
we estimated that 212,000 women were treated for com-
plications associated with induced abortion in Nigeria’s
sequences of such abortions; topics included the types of
providers from whom women obtain abortions, the likeli-
hood that these abortions result in complications and the
likelihood that women obtain treatment at a facility for
these complications. Study investigators and the research
team prepared a list of health professionals knowledgeable
about the conditions of abortion provision and postabor-
tion care. Interviewers and supervisors from each geopolit-
ical zone contributed to the list, ensuring adequate repre-
sentation of all zones. We drew on membership directories
of relevant professional associations to further broaden
the list; we intentionally avoided selecting individuals who
had participated in the Health Facilities Survey.
The resulting purposive sample of 194 respondents
spanned a wide range of professions, including doctors,
nurses and midwives (54%); program managers and
health administrators (12%); policymakers, legal prac-
titioners and activists (16%); lecturers and researchers
(15%); and other experts (4%; Appendix Table 2). We in-
cluded both medical and nonmedical participants because
evidence indicates that estimates of the parameters under
investigation may differ substantially between these two
groups.6
The representation of medical providers varied
from 44% in the South South region to 67% in the South
East. About 54% of the sample was from the north, 75%
were working in the public sector and 43% either were
currently working in rural areas or had done so in the past
five years (not shown). All interviews were conducted in
person by a small number of trained interviewers using a
structured questionnaire.
Analysis
The first step of our analysis was to estimate the number
of women who receive treatment for induced abortion
complications in Nigeria’s health facilities. Health Facilities
Survey respondents were not asked to provide separate es-
timates for induced and spontaneous abortions, because
complications of the two often are difficult to distinguish,
and because restrictive abortion laws may deter accurate re-
porting. Thus, it was necessary to estimate and subtract the
number of cases involving complications of spontaneous
abortion. To do this, we applied an indirect method based
on clinical studies that established the biological pattern of
spontaneous abortion. Using this approach, we estimated
that the number of miscarriages that occur at 13–22 weeks’
gestation (i.e., those likely to require facility-based care)
was equal to 3.4% of the number of live births.6
For various reasons, including constraints on access
to care, not all women who need care for late spontane-
ous abortions receive treatment at health facilities. We
assumed that among Nigerian women who require such
care, the proportion who receive care is the same as the
proportion of women giving birth who receive antenatal
care in a health facility—41% in the North West, 49% in the
North East, 67% in the North Central, 91% in the South
East, 73% in the South South, 90% in the South West and
61% nationally, according to the 2008 NDHS. Using these

174
Number and Rates of Induced Abortion
The multipliers, which account not only for women who
did not receive care for complications but also those who
did not have complications, ranged from 3.9 in the South
East to 8.4 in the North West (Table 3). Application of
these multipliers yields an estimate that 1.25 million in-
duced abortions occurred in Nigeria in 2012; our lower
and upper estimates are 963,000 and 1.54 million. Overall,
we estimate that the national induced abortion rate was 33
per 1,000 women aged 15–49 (confidence interval, 25–40
per 1,000), somewhat higher than the estimated rate of 25
per 1,000 women aged 15–44 (or 23 per 1,000 women
health facilities in 2012 (Table 3). These cases accounted
for 60% of all women treated for any abortion-related com-
plication in 2012 (not shown).
However, not every woman who has complications
from unsafe abortion serious enough to require treatment
in health facilities obtains the care she needs. According
to estimates from the Health Professionals Survey, 40% of
women who had an abortion in 2012 had complications
warranting treatment in a facility. On the basis of this pro-
portion, we estimate that an additional 285,000 women (or
seven per 1,000 women aged 15–49) had abortion compli-
cations but did not receive care that year (not shown).
TABLE 2.Estimated number of women treated for complications of spontaneous or induced abortions,and associated measures,by facility type,
according to geopolitical zone,Nigeria,2012
Facilitytype Geopoliticalzone All
NorthWest NorthEast NorthCentral SouthWest SouthSouth SouthEast
NUMBEROFWOMENTREATED
Public/government 42,501 37,955 24,300 35,570 25,009 25,631 190,967
Teachinghospital/FMC 3,765 3,236 5,052 5,205 8,357 12,297 37,912
General/specialisthospital 35,061 21,418 8,543 25,668 10,591 11,650 112,931
Cottagehospital/CHC/clinic 797 2,136 6,575 4,616 6,062 1,645 21,831
Maternitycenter 2,878 11,165 4,130 81 0 40 18,293
Private* 27,724 10,584 23,717 23,603 47,775 30,026 163,429
Hospital 10,794 5,268 12,327 21,759 23,178 18,686 92,012
Clinic/medicalcenter 2,861 2,090 1,399 1,078 21,516 850 29,794
Maternitycenter 14,068 3,226 9,990 767 3,082 10,490 41,624
Total 70,225 48,539 48,017 59,173 72,784 55,658 354,397
PERCENTAGES/RATES
%ofcomplicationstreatedinpublicfacilities 61 78 51 60 34 46 54
Treatmentrate 7.7 10.0 8.8 9.5 9.4 11.9 9.3
Public/governmentfacilities 4.6 7.8 4.5 5.7 3.2 5.5 5.0
Privatefacilities 3.0 2.2 4.4 3.8 6.2 6.4 4.3
*Includes 31 facilities run by nongovernmental organizations or missions. Notes: All values are adjusted to correct for misclassification.Treatment rate refers to number of women who re-
ceived treatment in the specified facilities per 1,000 women aged 15–49 in the general population.Sums of values may not equal totals because of rounding.FMC=Federal medical center.
TABLE 3. Measures used to estimate abortion levels,and key indicators of incidence,by geopolitical zone,Nigeria,2012
Measure
Zone
All
NorthWest NorthEast NorthCentral SouthWest SouthSouth SouthEast
ABORTION-RELATED
No.oflatemiscarriages 66,340 33,574 31,212 38,973 29,582 23,122 222,802
No.ofwomentreatedforabortioncomplications 70,225 48,539 48,017 59,173 72,784 55,658 354,397
No.ofwomentreatedforcomplicationsofspontaneousabortion 27,199 16,552 20,912 35,231 21,595 20,948 142,438
No.ofwomentreatedforcomplicationsofinducedabortion 43,025 31,987 27,105 23,942 51,189 34,710 211,959
%oftreatedcomplicationsduetoinducedabortion 61 66 56 40 70 62 60
Multiplier 8.4 7.2 5.5 6.9 4.2 3.9 na
No.ofabortions 360,552 229,029 147,723 164,003 214,483 134,326 1,250,117
Lowerestimate 300,270 182,584 117,475 98,807 178,896 84,758 962,791
Upperestimate 420,834 275,474 177,970 229,200 250,071 183,894 1,537,443
DEMOGRAPHIC
No.ofwomenaged15–49 11,636,504 5,649,521 5,459,670 6,186,806 4,842,436 4,385,825 38,160,762
No.oflivebirths 1,945,456 984,578 915,300 1,142,895 867,514 678,052 6,533,794
RATES/RATIOS
Inducedabortionrate* 31.0 40.5 27.1 26.5 44.3 30.6 32.8
Lowerestimate 25.8 32.3 21.5 16.0 36.9 19.3 25.2
Upperestimate 36.2 48.8 32.6 37.0 51.6 41.9 40.3
Inducedabortionratio† 18.5 23.3 16.1 14.3 24.7 19.8 19.1
Inducedabortiontreatmentrate‡ 3.7 5.7 5.0 3.9 10.6 7.9 5.6
*Number of abortions per 1,000 women aged 15–49. †Number of abortions per 100 live births. ‡Number of women receiving postabortion care per 1,000 women aged 15–49. Sources:
Abortion-related measures—Health Facilities Survey and Health Professionals Survey.No.of women aged 15–49—reference 11.No.of live births—Calculated from data in reference 10.

of pregnancies in 2012 were unintended; the proportion
was lowest in the North West (16%) and highest in the
South South (38%).
The majority of Nigerian women’s pregnancies in 2012
ended in planned births. The proportion was 63% for the
country as a whole, and ranged from 52% in the South
South to 70% in the North West. About 14% of pregnan-
cies ended in abortion; the proportion varied from 11%
in the South West to 17% in the South South. At the na-
tional level, about 56% of unintended pregnancies ended
in abortion (not shown); regionally, the proportion was
lowest in the South West (43%) and highest in the North
East (64%) and North West (81%). Fewer than half of un-
intended pregnancies in the three southern regions ended
in abortion.
DISCUSSION
Mortality and Morbidity due to Unsafe Abortion
Nigeria has one of the highest maternal mortality ratios in
the world.18
Although the government has acknowledged
the problem and is committed to improving maternal
health, evidence suggests that progress has been limited,
and unsafe abortion remains a major contributor to mater-
aged 15–49) in 1996. Because of the large differences in
the quality of reporting of clandestine abortion services,
the two studies used different adaptations of the AICM,
and deriving conclusions from a comparison of the data is
difficult. However, the 1996 abortion rate of 23 per 1,000
women 15–49 falls just outside the confidence interval for
the 2012 rate, suggesting that abortion incidence may have
increased somewhat between 1996 and 2012.
Regional abortion rates varied widely. They were lowest
in the North Central and South West zones (27 per 1,000
in each), slightly higher in the North West and South East
zones (31 per 1,000 in each) and highest in the North East
(41 per 1,000) and South South (44 per 1,000). To further
put the number of induced abortions in context, the abor-
tion ratio (number of abortions per 100 live births) was
19 per 100 nationally, and ranged from 14 per 100 in the
South West to 25 per 100 in the South South.
Pregnancies andTheir Outcomes
Obtaining a plausible estimate of the number of abor-
tions allowed us to estimate the number of pregnancies
that occurred in Nigeria in 2012. This number is the sum
of the numbers of induced abortions, births and sponta-
neous abortions among women aged 15–49. To estimate
the number of births, we applied age-specific fertility rates
from the NDHS to the number of Nigerian women in five-
year age-groups. Estimates of spontaneous abortion were
calculated according to the formula (derived from clinical
studies of pregnancy loss) that the number of spontane-
ous abortions occurring at five or more weeks’ gestation is
approximately equal to 20% of the number of births plus
10% of the number of induced abortions.16,17
These calculations indicate that women aged 15–49 had
about 9.22 million pregnancies in Nigeria in 2012 (Table
4). The overall pregnancy rate was 241 pregnancies per
1,000 women in this age-group. The rate was lowest in the
South East (219) and highest in the South South (264).
The national unintended pregnancy rate was 59 per 1,000
women aged 15–49; regionally, the rate ranged from 38 in
the North West to 100 in the South South. Nationally, 24%
TABLE 4. Selected pregnancy-related measures,and percentage distribution of pregnancies by outcome,all according to
geo-political zone,Nigeria,2012
Measure NorthWest NorthEast NorthCentral SouthWest SouthSouth SouthEast All
No.ofpregnancies 2,731,155 1,433,426 1,260,854 1,551,877 1,276,948 961,421 9,215,682
Pregnancyrate* 235 254 231 251 264 219 241
Unintendedpregnancyrate† 38 64 51 62 100 66 59
%ofpregnanciesthatwereunintended 16 25 22 25 38 30 24
Pregnancyoutcomes
Birthfromplannedpregnancy 70 62 65 63 52 58 63
Miscarriageofplannedpregnancy 14 12 13 13 10 12 13
Abortion 13 16 12 11 17 14 14
Birthfromunplannedpregnancy 2 6 8 11 16 12 8
Miscarriageofunplannedpregnancy 2 3 3 3 5 4 3
Total 100 100 100 100 100 100 100
*Annual number of pregnancies per 1,000 women aged 15–49.†Annual number of unintended pregnancies per 1,000 women aged 15–49. Note:Sums of per-
centages may not equal 100 because of rounding.
Table 5.Selected characteristics women aged 15–49,by geographic zone,Nigeria
Demographic and Health Survey,2013
Characteristic Zone All
North
West
North
East
North
Central
South
West
South
South
South
East
%livinginurbanarea 29 27 27 77 39 70 42
%with≥7yrs.ofeducation 19 22 45 72 72 74 45
%married 85 81 70 66 55 52 72
%Catholic/Protestant 10 16 54 64 97 98 47
%Muslim 90 83 44 35 2 0.3 52
%usinganycontraceptivemethod 5 3 14 33 29 27 16
%usingamodernmethod 4 3 11 23 18 14 11
%withunmetneedforcontraception 11 16 19 12 18 10 14
%ofbirthsunplanned* 2 9 10 15 24 18 10
%ofbirthsmistimed* 2 8 8 11 20 13 8
%ofbirthsunwanted* 0.2 1 3 4 4 5 2
Totalfertilityrate 6.7 6.3 5.3 4.6 4.3 4.7 5.5
Wantedfertilityrate 6.5 6.1 4.8 4.2 3.9 4.3 5.2
*In past three years.Source: reference 10.

176
had done so within the past year.
Evidence from national surveys suggests that the num-
ber of abortions in Nigeria is likely to remain high in the ab-
sence of intervention. According to the 2013 NDHS, Nigeri-
an women aged 15–49 had, on average, more children than
they wanted (Table 5).10
Although the difference between
total fertility and wanted fertility was not large, women in
all six geopolitical zones had more children than they de-
sired. The prevalence of contraceptive use remained at vir-
tually the same low level as in the 2008 NDHS—only 16%
of women of reproductive age were using a method, and
only 11% were using a modern method, in 2013.10
In addi-
tion, 14% of women aged 15–49—and 22% of sexually ac-
tive unmarried women in this age group (not shown)—had
an unmet need for contraception, meaning that they did
not want to have a child in the next two years or wanted no
more children at all, but were not using any contraceptive
method (Table 5). Women with unmet need commonly
cite opposition to contraception (their own, their partner’s
or that of another person, such as a family member) and
fear of side effects as reasons for nonuse.24
The high rates of abortion in the North East and South
South are likely related to factors that increase women’s
need for abortion in these regions. The proportion of wom-
en in the North East who use contraceptives is the lowest
in the country (3%), and the level of unmet need (16%) is
higher than average. Although the social and demographic
characteristics and contraceptive behavior of women in
the North East are similar to those of their counterparts in
the neighboring North West zone, the abortion rates dif-
fer greatly (41 vs. 31 per 1,000 women aged 15–19). This
difference, together with the slightly higher rates of total
fertility and wanted fertility in the North West compared
with the North East, suggest that women in the former
zone are more likely than those in the latter to carry their
pregnancies to term.
Women in the three southern regions want smaller
families (3.9–4.3 children) than do women in the north-
ern regions (4.8–6.5), which may indicate that women in
the southern regions have a relatively strong desire to limit
their family size. Although the South South ranks second
in the proportions of women using any contraceptive
method (29%) and any modern method (18%), it also has
the second highest level of unmet need (18%). This sug-
gests that compared with women in other regions, those
in the South South may be relying on abortion to a greater
degree, and on contraception to a lesser degree, to achieve
the smaller families they desire.
Limitations
Like other indirect estimation techniques, the AICM has
limitations. The data on the number of postabortion care
cases treated in health facilities—a key input variable in
our calculation of abortion incidence—are derived from
respondents’ estimates. We must rely on these estimates
because facilities’ official records are frequently inaccurate,
grossly incomplete or nonexistent. We believe that a shift
nal morbidity and mortality.
In a community-based survey conducted in 2002–2003,
25% of women who had had an induced abortion report-
ed having had serious complications.19
Another study
found that women who had been admitted to hospitals for
complications of induced abortion had suffered a variety
of complications, including retained products of concep-
tion (50%), bleeding (34%) and fever (34%).20
Two-thirds
had had serious complications, such as sepsis, pelvic infec-
tions and injury from instruments, and some died.
A recent study recorded 137 maternal near-miss cases*
in a six-month period at eight large hospitals across the
country, and found that 13 (10%) were due to unsafe
abortion.21
Another study estimated that in the late 1990s,
about 3,000 women died annually from unsafe abortion in
Nigeria.20
Because this estimate included only women who
had died in health facilities, and not those who had died
from unsafe abortion before reaching a facility, the actual
number of deaths was likely higher.
We estimate that in 2012, about 212,000 women were
treated in health facilities for complications of induced
abortion, suggesting that unsafe abortion remains an im-
portant contributor to maternal morbidity and mortal-
ity in Nigeria. In addition, an estimated 285,000 women
had complications serious enough to require treatment in
health facilities, but did not obtain the care they needed.
The impact of unsafe abortion extends beyond morbid-
ity and mortality; there are also social costs to Nigerian
women and their households, including the risks associ-
ated with breaking the country’s restrictive abortion law
and the possibility of strong social sanctions.
Furthermore, unsafe abortion imposes a heavy finan-
cial burden on both women and Nigeria’s fragile health
care system. For example, one study estimated that post-
abortion care cost US$103 per patient in Nigeria in 2005,
amounting to US$19 million; the average per-case cost for
hospital care was US$132, of which 72% (US$95) was
borne by women and their households.22
Unintended Pregnancy and Abortion
Findings from this study suggest that unintended preg-
nancy—the root cause of most abortions—is still occurring
at moderately high levels in Nigeria. The high rates of un-
intended pregnancy and abortion are probably due largely
to the combination of low prevalence of contraceptive use
(especially use of modern methods) and the high propor-
tion of women who need methods to avoid unwanted
births or (particularly in the case of sexually active unmar-
ried young women) to delay their first pregnancy. Women
with the latter need are not an insignificant group: Accord-
ing to the 2013 NDHS, 40% of never-married women aged
15–19 had had sex, and about three-quarters of this group
*A near-miss maternal event is the near-death of a woman from a com-
plication during pregnancy or childbirth or within 42 days of the termi-
nation of pregnancy (source: Say L, Souza JP and Pattinson RC, Maternal
near miss—towards a standard tool for monitoring quality of maternal
health care,Best Practice and Research,2009,23(3):287–296).

In 2012, at the Family Planning 2020 Summit in Lon-
don, the Nigerian government made a commitment to
increase the contraceptive prevalence rate to 36% by
2018 and to raise total spending on reproductive health
commodities from US$12 million to US$45.4 million by
2016.25
While this step is laudable, achieving the goal
of 36% will require not only that the government fulfill
its financial commitment, but, equally importantly, that
it be strategic in its choices of programs to pursue. The
government of Ethiopia has shown, with its very success-
ful Health Extension Program, that such a strategy is pos-
sible.26
The Nigerian government should carry out an as-
sessment to identify the types of programs that will work
best in the Nigerian context.
Because it typically takes time to see the effects on per-
sonal behavior of even the best policies and programs, and
because contraceptive failures happen even among users
of modern methods, some women will still seek unsafe
abortions, at least in the short run. To help such women
avoid long-term disability and even death, the government
should continue to increase and improve access to appro-
priate, adequate and timely postabortion care services.
Such efforts should focus on providing access to mod-
ern, appropriate and relatively noninvasive methods of
postabortion care, such as manual vacuum aspiration and
misoprostol; providing adequate training for relevant cad-
res of health providers; legally permitting and equipping
midlevel health practitioners to provide postabortion care;
and training providers to treat clients in a nonjudgmen-
tal manner. In addition, although only a small number of
women may be eligible for legal abortion under the current
law, which permits abortion only to save a woman’s life, an
efficient process should be established to enable eligible
women to have access to safe abortion services. To ensure
that such abortions are performed safely, the government
should promote training in the provision of safe abor-
tion services at medical schools, during housemanship
(postqualification training for young doctors, usually dur-
ing their first two years) and during internships for medi-
to social and religious conservatism has greatly affected
the accuracy of facilities’ reporting of abortion provision
in Nigeria; while respondents may be able to report rea-
sonably accurate estimates of clandestine abortion services
and of postabortion complication care, a comparison of es-
timates from this study with those from the previous one
strongly suggests that many respondents grouped the two
services together as postabortion complication cases in
their reports, thus greatly reducing the reporting of abor-
tions. Consequently, to calculate abortion estimates more
realistically, we had to make several adjustments to ensure
realistic abortion estimates. Moreover, to correct for notice-
able underestimates and overestimates of postabortion
care caseloads in some regions and facilities, we assumed
that service provision in these regions and facilities was
similar to that in some neighboring regions and facilities.
These adjustments likely resulted in a conservative esti-
mate of abortion incidence in Nigeria.
Lastly, lacking any direct information on this topic,
we calculated the required multipliers using data on the
perceptions of health professionals. While these respon-
dents were carefully chosen and have extensive expertise
on abortion-seeking behavior, the resulting multipliers are
not exact measures; thus, we present confidence intervals
around the estimates of abortion incidence.
Implications for Policies and Programs
Given the extent to which unsafe abortions are still occur-
ring in Nigeria, there is strong need for the government and
local and international stakeholders to make more concert-
ed efforts to ensure that women do not continue to suffer
or die needlessly from unsafe abortion. Since unintended
pregnancy is the reason for most abortions, the most im-
portant—and least expensive—step is to promote access to
contraceptive services to prevent such pregnancies. Pro-
grammatic efforts should strive to increase coverage, pro-
vide a wide range of contraceptive methods and improve
the quality of care; women should have access to counsel-
ing and be able to switch methods easily when needed.
APPENDIX TABLE 1. Characteristics of participating facilities,by type,Health Facilities Survey
Facilitytype N Mean
no.of
beds
%
Provides
inpatient
services
Provide
outpatient
services
Hasfunctional
MVA
equipment
Hasstaff
trained
inMVA
Has
surgical
ward
Hasseparate
evacuation
ward
Provides
induced
abortion
Public/government(N=369)
Teachinghospital/FMC 47 272 100 100 98 98 100 84 14
General/specialisthospital 171 84 100 99 85 88 100 45 7
Cottagehospital/CHC/clinic 78 20 85 92 50 61 35 9 1
Maternitycenter 73 6 87 98 10 22 4 3 4
Private(N=403)*
Hospital 263 28 99 100 72 78 96 31 8
Clinic/medicalcenter 68 15 99 97 83 90 93 14 21
Maternitycenter 72 13 97 97 62 75 68 15 7
All 772 31 96 98 62 70 71 23 8
*Includes 31 facilities operated by nongovernmental organizations or missions. Note: MVA=manual vacuum aspiration. FMC=Federal medical center.

178
Nigerian women, International Family Planning Perspectives, 2006,
32(4):175–184.
5. Government of the Federal Republic of Nigeria, Nigeria Millennium
Development Goals Report 2010, Abuja, Nigeria: Government of the
Federal Republic of Nigeria, 2010.
6. Singh S, Prada E and Juarez F, The abortion incidence
complications method: a quantitative technique, in: Singh S, Remez L
and Tartaglione A, eds., Methodologies for Estimating Abortion Incidence
and Abortion-Related Morbidity: A Review, New York: Guttmacher
Institute, 2011.
7. Sedgh G et al., Estimating abortion incidence in Burkina Faso using
two methodologies, Studies in Family Planning, 2011, 42(3):147–154.
8. Juarez F and Singh S, Incidence of induced abortion by age and
state, Mexico, 2009: new estimates using a modified methodology,
International Perspectives on Sexual and Reproductive Health, 2012,
38(2):58–67.
9. Sedgh G et al., Estimates of the incidence of induced abortion and
consequences of unsafe abortion in Senegal, International Perspectives
on Sexual and Reproductive Health, 2015, 41(1):11–19.
10. National Population Commission and ICF International, Nigeria
Demographic and Health Survey 2013, Abuja, Nigeria: National
Population Commission; and Rockville, MD, USA: ICF International,
2014.
11. Population Division, United Nations (UN) Department of
Economic and Social Affairs, World Population Prospects: The 2012
Revision, New York: UN, 2013.
cal students and personnel. Steps should also be taken to
ensure that women seeking legal abortions have access to
the procedure as early as possible, so that they can benefit
from the use of modern, less invasive methods.
When women and couples begin to want smaller fami-
lies—and continue to be motivated to space their births
and avoid premarital childbearing—they will use a combi-
nation of means, such as modern or traditional contracep-
tive methods and abortion, to achieve their goals.27
Unless
adequate measures are taken to prevent unwanted preg-
nancy and unsafe abortion, the health and well-being of
women will continue to be at risk in Nigeria.
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1. Center for Reproductive Rights, Nigeria’s abortion provisions, no
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abortion-provisions.
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Regional Estimates of the Incidence of Unsafe Abortion and Associated
Mortality in 2008, Geneva: WHO, 2011.
3. Henshaw SK et al., The incidence of induced abortion in Nigeria,
International Family Planning Perspectives, 1998, 24(4):156–164.
4. Sedgh G et al., Unwanted pregnancy and associated factors among
APPENDIX TABLE 2.Percentage distribution of survey respondents,by occupation,according to geopolitical zone,Health
Facilities Survey and Health Professionals Survey
Respondent N Geopoliticalzone All
North
West
North
East
North
Central
South
West
South
South
South
East
HealthFacilitiesSurvey
Physician/medicalofficer 404 50.4 21.9 48.6 62.2 71.4 69.4 52.3
Nurse/midwife 252 35.9 43.2 33.3 28.1 27.7 24.1 32.6
CHEW/CHO 111 13.7 32.9 17.4 8.9 0.8 6.5 14.4
Other 5 0.0 1.9 0.7 0.7 0.0 0.0 0.6
Total 772 100.0 100.0 100.0 100.0 100.0 100.0 100.0
HealthProfessionalsSurvey
Physician 57 13.9 38.5 20.7 16.7 37.0 40.0 29.4
Othermedicalprofessional 47 36.1 15.4 27.6 33.3 7.4 26.7 24.2
Programmanager/healthadministrator 23 13.9 7.7 10.3 16.7 22.2 6.7 11.9
Policymaker/politician/lawyer/judge/activist 29 16.7 15.4 13.8 16.7 18.5 15.6 16.0
Lecturer/teacher/researcher 31 16.7 17.9 24.1 16.7 11.1 6.7 14.9
Other 7 2.8 5.1 3.4 0.0 3.7 4.4 3.6
Total 194 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Notes:CHEW=community health extension worker.CHO=community health officer.
APPENDIX TABLE 3.Percentage distribution of Health Facility Survey respondents,by level of training,according to facility
type
Leveloftraining N Government Private*
Teaching
hospital/
FMC
General/
specialist
hospital
Cottage
hospital/
CHC/clinic
Maternity
center
Hospital Clinic/
Medical
center
Maternity
center
Physician/medicalofficer 404 72 45 26 4 70 66 55
Nurse/midwife 252 26 49 50 35 25 19 20
CHEW/CHO 111 2 5 24 58 5 15 24
Other 5 0 1 0 3 0.4 0 0
Total 772 100 100 100 100 100 100 100
*Includes facilities operated by nongovernmental organizations and missions.Notes: FMC=Federal medical center CHC= Comprehensive health center.
CHEW=community health extension worker.CHO=community health officer.

12. Abdulkadir A et al., Medical record system in Nigeria:
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patients’ information documentation practices, Journal of Medicine
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14. Iyioha IO and Nwabueze RN, eds., Comparative Health Law and
Policy: Critical Perspectives on Nigerian and Global Health Law, Surrey,
UK: Ashgate Publishing, 2015.
15. Okonofua FE et al., Perceptions of policymakers in Nigeria toward
unsafe abortion and maternal mortality, International Perspectives on
Sexual and Reproductive Health, 2009, 35(4):194–202.
16. Bongaarts J and Potter RG, Fertility, Biology, and Behavior: An
Analysis of the Proximate Determinants, New York: Academic Press,
1983.
17. Leridon H, Human Fertility: The Basic Components, Chicago, IL,
USA: University of Chicago Press, 1977.
18. WHO et al., Trends in Maternal Mortality: 1990 to 2013. Estimates
by WHO, UNICEF, UNFPA, The World Bank and the United Nations
Population Division, Geneva: WHO, 2014.
19. Bankole A et al., Unwanted Pregnancy and Induced Abortion in
Nigeria: Causes and Consequences, New York: Guttmacher Institute,
2006.
20. Henshaw SK et al., Severity and cost of unsafe abortion
complications treated in Nigerian hospitals, International Family
Planning Perspectives, 2008, 34(1):40–50.
21. Prada E et al., Maternal near-miss due to unsafe abortion and
associated short-term health and socioeconomic consequences in
Nigeria, African Journal of Reproductive Health, 2015, 19(2):52–62.
22. Bankole A et al., Estimating the cost of post-abortion care in
Nigeria: a case study, in: Lule E, Singh S and Chowdhury SA, eds.,
Fertility Regulation Behaviors and Their Costs, Washington, DC: World
Bank, 2007.
23. National Population Commission, Nigeria and ICF Macro,
Nigeria Demographic and Health Survey 2008, Abuja, Nigeria: National
Population Commission and ICF Macro, 2009.
24. Sedgh G and Hussain R, Reasons for contraceptive nonuse among
women having unmet need for contraception in developing countries,
Studies in Family Planning, 2014, 45(2):151–169.
25. British Directorate for International Development (DFID) and
the Bill and Melinda Gates Foundation, London Summit on Family
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www.gov.uk/government/uploads/system/uploads/attachment_
data/file/67328/london-summit-family-planning-commitments.pdf.
26. Olson DJ and Piller A, Ethiopia: an emerging family planning
success story, Studies in Family Planning, 2013, 44(4):445–459.
27. Berer M, Making abortions safe: a matter of good public health
policy and practice, Bulletin of the World Health Organization, 2000,
78(5):580–592.
APPENDIX: METHODOLOGICAL DETAILS OF
CALCULATING ABORTION INCIDENCE IN NIGERIA
In this appendix, we present details regarding some of the
adjustments and calculations we made in estimating the
number of induced abortions in Nigeria.
Adjustments to Postabortion Care Caseload
Because the collection and initial analyses of data from the
Health Facilities Survey identified clear patterns of misre-
porting, and one case of inadequate sample representa-
tion, we made several adjustments to the estimates of the
number of women treated in health facilities for complica-
tions of abortion.
•Adjustment for misreporting of abortions. The first prob-
able indication of substantial misreporting was the obser-
vation during fielding of the Health Facilities Survey that
respondents were reporting very low numbers of induced
abortions, even in the types of facilities generally known
to be large providers of these services. This reluctance to
provide information on induced abortion, but not on post-
abortion care, continued throughout fieldwork, despite
efforts to reassure respondents that the information they
provided would be kept confidential. On the basis of find-
ings from the 1996 Nigerian abortion incidence study1
and
from other incidence studies in the region (e.g., in terms
of typical case loads for given sizes and types of facilities),
we concluded that because induced abortion is highly re-
stricted in Nigeria, many abortion procedures were being
provided clandestinely (mainly in private facilities), and
that many induced abortion services were being reported
as postabortion care services, resulting in underreporting
of the former and overreporting of the latter.
For example, in the 1996 study, the ratio of reported
postabortion care cases to reported abortion cases in
private facilities was 51:49. In 2012, the ratio was 90:10.
Because we had no information suggesting that private
facilities across Nigeria had stopped providing abortions
(on the contrary, anecdotal evidence indicates that abor-
tion continues to be a commonly provided service at these
facilities), we assumed that the ratio had not changed
since 1996. To correct for this misreporting, we adjusted
the 2012 data to reflect the 1996 case ratio of abortion to
postabortion care.
•Adjustment for reference period length. We made a second
adjustment to take into account an unexpected conse-
quence of using a shorter reference period in the Health
Facilities Survey than is typically used in the Abortion In-
cidence Complications Methodology (AICM). For the first
time in an AICM study, the 2012 Nigerian Health Facili-
ties Survey asked respondents to estimate the number of
postabortion care cases treated at their facility in a week; if
they were not able to do so (probably because the caseload
was small or they tended to assess caseloads in terms of a
longer duration), they were asked to report the number of
cases in a month or, if they preferred, in a year. The stan-
dard AICM approach only asks the respondent to provide
estimates for a month or year; we added the shorter refer-
ence period (one week) because we thought respondents
from larger facilities would find it easier to estimate for a
shorter time period. Although respondents were asked
to answer for one time period, several reported for mul-
tiple periods, which allowed us to compare the annual
equivalents for these estimates. This check revealed that
estimates of weekly caseloads yielded much higher annual
totals than did estimates of monthly caseloads; for exam-
ple, what would be a minor overestimation of one case in

180
ments resulted in lower postabortion caseloads, and hence
lower rather than higher estimates of abortion incidence.
Furthermore, without these adjustments, the resulting
estimated abortion rates would have been too high to be
realistic or defensible, given other relevant evidence from
Nigeria and West Africa, including estimates of abortion
incidence and fertility and contraceptive behavior.
Calculation of the Multipliers
Health professionals who took part in the Health Profes-
sionals Survey were asked to make several estimates, in-
cluding the percentage distribution of women who had
abortions according to the type of provider they used;
the proportion of these women who had complications,
according to the type of provider they used; and the pro-
portion of women with complications who obtained care
from a health facility. Recognizing that the circumstances
under which women obtain abortions in Nigeria vary by
women’s area of residence and socioeconomic status, we
asked survey participants to provide the aforementioned
estimates separately for four subgroups of women: urban
poor, urban nonpoor, rural poor and rural nonpoor. Be-
cause medical and nonmedical respondents have some-
what different areas of expertise concerning abortion ser-
vice provision and may provide different estimates of these
parameters, we calculated estimates separately for the two
groups and used the unweighted average of the results.
The estimates from the health professionals were
weighted by the relative size of the four subgroups of wom-
en. We then calculated the multiplier (see main article)
for each geopolitical zone as the inverse of the estimated
proportion of abortion recipients in the zone who received
care in health facilities for complications. In mathematical
terms, calculation of the multiplier would be expressed in
the following terms:
Suppose:
Ajk
=% of women who have an abortion complication, by
subgroup
Bjk
=% of women with complications who obtain care in
a health facility, by subgroup
Cjk
=% obtaining treatment for complications in a health
facility, among all women having abortions, by subgroup
W=distribution of the population of women according
to subgroup
Where:
j=subgroup (rural poor, rural nonpoor, urban poor, ur-
ban nonpoor) and
k= type of respondent (medical/nonmedical)
Then:
Cjk
=(Ajk
*Bjk
)
D=Sum(W * Cjk
) (i.e., weighted % of women who had an
abortion who received treatment)
Multiplier (M)=1/D
a weekly estimate would be inflated to 52 extra cases per
year. In light of our earlier observation that facilities were
overreporting postabortion care caseloads, we determined
that facilities reporting estimates by the week were more
likely than those reporting by the month to have contrib-
uted to the overestimation of postabortion care cases.
Given this pattern, and because this study was the first
to use weekly reporting with the AICM methodology, we
concluded that to achieve a close approximation to the
standard approach of using monthly reporting, we must
adjust the caseload for facilities that provided only weekly
estimates. We therefore used the ratio of the annual total
based on months to that based on weeks (among facilities
for which data for both reference periods were available)
to adjust downward the annual totals for facilities with
only weekly data. This resulted in a 24% reduction in the
number of postabortion care cases from the unadjusted
national total.
•Adjustment for high caseloads in the North East. An ad-
ditional adjustment was made only to data from the North
East zone, where average postabortion care caseloads were
notably higher than the caseloads at facilities with similar
capacities in other zones, including the North West, which
is the zone most similar to the North East in terms of resi-
dents’ socioeconomic and demographic characteristics.
To correct for this anomaly, we reduced postabortion care
caseload estimates for the North East so that the ratio of
average caseload to average number of beds equaled that
of facilities in the same category in the North West zone.
•Adjustment for underrepresentation of public facilities in
the South East. A fourth adjustment was made only for the
South East zone, where public facilities were poorly repre-
sented in the Health Facilities Survey, resulting in excep-
tionally low average postabortion care caseloads in this
sector. To correct for this, we adjusted the caseloads so that
the ratio of the average number of postabortion care cases
to the average number of beds in each type of public facil-
ity in the zone was similar to the ratio in the South West
and South South zones combined. Again, we took this step
because the South West and South South zones are most
similar to the South East in terms of their sociocultural and
demographic profiles.
•Overall effect of adjustments. In total, the adjustments de-
scribed above reduced the number of reported postabor-
tion care cases by 43%. We acknowledge that the assump-
tions behind these adjustments are a limitation of our
analysis. However, the adjustments were made using the
best available information about abortion service provi-
sion, drawing on detailed information from the 1996 study
and on our understanding of the context of abortion and
postabortion service provision in the country. In addition,
the direction of possible bias that may result from these
adjustments is clear. The adjustment to public facility case-
loads in the South East, which had the smallest impact on
our overall estimates, led to an increase in the number of
postabortion cases, and an increase in the estimate of abor-
tion incidence for that zone. The remaining three adjust-

grossesses non planifiées sont interrompues. Environ 212 000
femmes ont été traitées pour complications d’un avortement
non médicalisé, soit un taux de traitement de 5,6 pour 1 000
femmes en âge de procréer, tandis que 285 000 autres souf-
fraient de conséquences de santé graves sans toutefois obtenir
les soins nécessaires.
Conclusion: Les taux de grossesse non planifiée et d’avorte-
ment non médicalisé restent élevés au Nigéria. L’amélioration
de l’accès aux services de contraception et de la prestation de
services d’avortement médicalisé et de soins après avortement
(dans la mesure permise par la loi) pourrait aider à réduire la
morbidité et la mortalité maternelles.
Acknowledgments
The authors gratefully acknowledge comments and feedback
provided on earlier drafts of this paper by Dee Wulf. The authors
alsothankCalvinChama,EmilyNzeribe,A.O.Oguntayo,Anthony
Okonkwo and Rakiya Saidu for coordinating and supervising
the data collection process. This study was supported by funding
from the Dutch Ministry of Foreign Affairs, the UK Government
and The John D. and Catherine T. MacArthur Foundation. The
findings and conclusions in this article do not necessarily reflect the
positions and policies of the donors.
Author contact:abankole@guttmacher.org
RESUMEN
Contexto: Debido a la baja prevalencia de uso de anticon-
ceptivos en Nigeria, un importante número de mujeres tienen
embarazos no planeados, muchos de los cuales se resuelven a
través de abortos clandestinos a pesar de la restrictiva ley de
aborto del país. Es necesario contar con estimaciones actuali-
zadas de la incidencia del aborto.
Métodos: Se aplicó una metodología indirecta ampliamente
utilizada para estimar la incidencia del aborto y del embarazo
no planeado en Nigeria en 2012. Se recolectaron datos sobre la
provisión de servicios de aborto y postaborto a partir de una
muestra representativa a nivel nacional de 772 instituciones
de salud, y se obtuvieron estimaciones de la probabilidad de
que las mujeres que tienen abortos inseguros experimenten
complicaciones y reciban tratamiento, a partir de 194 profe-
sionales de la salud con un amplio conocimiento del contexto
del aborto en Nigeria.
Resultados: Se estima que en 2012 ocurrieron en Nigeria al-
rededor de 1 millón 250 mil abortos inducidos, lo que equivale
a una tasa de 33 abortos por 1,000 mujeres en edades de 15 a
49 años. La tasa estimada de embarazos no planeados fue de
59 por 1,000 mujeres en edades de 15 a 49 años. El cincuenta
y seis por ciento de los embarazos no planeados se resolvió
recurriendo al aborto. Cerca de 212,000 mujeres recibieron
tratamiento por complicaciones de abortos inseguros, lo que
representa una tasa de tratamiento de 5.6 por 1,000 mujeres
en edad reproductiva; y otras 285,000 mujeres experimenta-
ron graves consecuencias para su salud, pero no recibieron el
tratamiento que necesitaban.
Conclusión: Los niveles de embarazo no planeado y de abor-
to inseguro continúan siendo altos en Nigeria. Las mejoras en
el acceso a los servicios de anticoncepción, así como en la pro-
visión de servicios de aborto seguro y de atención postaborto
(según lo permita la ley), pueden ayudar a reducir la morbili-
dad y mortalidad materna.
RÉSUMÉ
Contexte: La faible prévalence contraceptive au Nigéria fait
que beaucoup de femmes se trouvent confrontées à des gros-
sesses non planifiées, souvent interrompues clandestinement,
en dépit de la législation restrictive de l’avortement dans le
pays. L’incidence actuelle de l’avortement doit être estimée.
Méthodes: Une méthodologie indirecte largement pratiquée
a servi à estimer l’incidence de l’avortement et de la grossesse
non planifiée au Nigéria en 2012. Les données relatives à la
prestation de l’avortement et de soins après avortement ont
été collectées auprès d’un échantillon nationalement repré-
sentatif de 772 établissements de santé. Les estimations de la
probabilité de complications de l’avortement non médicalisé et
d’obtention de soins l’ont été auprès de 194 professionnels de
la santé généralement au courant du contexte de l’avortement
au Nigéria.
Résultats: On estime à 1,25 million le nombre d’avorte-
ments provoqués au Nigéria en 2012, soit un taux de 33 IVG
pour 1 000 femmes âgées de 15 à 49 ans. Pour ce qui est des
grossesses non planifiées, le taux est estimé à 59 pour 1 000
femmes âgées de 15 à 49 ans. Cinquante-six pour cent des

The Incidence of Abortion in Nigeria.pdf

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The Incidence of Abortion in Nigeria.pdf